Asinof: When We Talk About Health, is the Mouth Part of the Body?

It seems like such an innocuous question, with many easy answers, something that most people hopefully do two or three times a day, as a normal part of their routine. And, floss, too.

I have often used the question as an integral part of my public speaking training when I do communications work.

What participants in the training discovered, however, was that it required them to talk about their own beliefs of self-image, and how that motivated their work or made them fearful to smile, or proud to be smiling. Our teeth and our gums are very much a litmus test for how we feel about ourselves.

These days, when primary care nurses and doctors are beginning to screen for depression, perhaps they should consider asking a question or two about brushing your teeth, because it can often serve as a revealing window into behavioral health and mental health issues.

A larger sense of decay

Underneath that personal question of self-image is a much larger, not often discussed truth about the massive decay in our health care delivery system around unmet dental needs for uninsured and under-insured residents, particularly for older Rhode Islanders.

If past is prologue, this weekend, on Saturday, Sept. 29, and Sunday, Sept. 30, we can expect that there will be long, long lines snaking outside the Providence Community Health Centers Dental Clinic on Prairie Avenue, when the two-day Rhode Island Mission of Mercy conducts its free dental clinic for those who cannot afford dental care.

The patient line is slated to open at 5:45 a.m. each morning. Patients who are seen will be able to undergo a health and dental evaluation, and then be provided with treatment on a first-come, first-served basis, with services provided by licensed dental professional volunteers.

The services provided will include fillings, X-rays, tooth extractions, root canal treatment on front teeth only, small denture repairs and a limited number of partial dentures to replace missing front teeth.

A health divide by wealth

As Dr. Sam Zwetchkenbaum, the dental director for the R.I. Department of Health’s Oral Health program as well as dental director for the state’s Medicaid program, told me in an interview earlier this year, for people over 65, the use of dental health services is highly dependent on wealth, according to the data. “People who had money continue to go to the dentist.”

The problem is three-fold.

Basic Medicare does not offer dental benefits; it requires an extra dose of insurance, at a higher cost.

Many dentists do not take Medicaid for adults, because of the poor reimbursement rates. “I’ll admit that adult services under Medicaid pay poorly,” Zwetchkenbaum said.

Even those who pay the extra cost for dental insurance may find themselves limited by the fine print of the policies, which limit dental services for things like root canal and crown repair, exacting high co-pays. For instance, a root canal may be billed at $1,200, but only $600 will be covered by dental insurance, requiring the patient to pay $600 as a co-pay. Ouch!

In terms of dental health literacy, Zwetchkenbaum offered a cautionary note: nationally, some 52 percent of people on Medicare think they have a dental benefit – “which means they haven’t gone to the dentist and asked about Medicare dental benefits,” he explained.

A solution, according to Zwetchkenbaum, would be to integrate comprehensive dental coverage as part of Medicare.

“We need to look at the fact that the mouth is part of the body,” he said. “I think there would be a lot of benefit to considering oral health as a Medicare benefit.”

It would be tough, politically, to push through such a change, he continued. “But, to me, it makes sense,” Zwetchkenbaum said, explaining that there were a large swath of people who are over 65, who are not on Medicaid, that do not have access to dental insurance.

Emergency room data

In Rhode Island, hospital discharge data showed that 2.6 percent of ED encounters, about 6,500 Rhode Islanders a year, were for non-traumatic dental purposes, according to Zwetchkenbaum.

The largest demographic being seen for non-traumatic dental purposes is the 21-34 age group; they are the lowest utilizers of preventive dental services, according to Zwetchkenbaum. Among teenagers who have Medicaid coverage, the percent for dental cleanings a year at age 12 is at 59 percent, but it drops to 48 percent for 16-year-olds.

Debate questions

This Thursday, Sept. 27, three of the 2018 candidates running for Governor will meet in a debate being held by WPRI.

As much as health care industry is the largest private employer in the state, and medical costs are one of the biggest drivers of the state budget, perhaps the biggest question to ask is this: how many questions will the moderators, Ted Nesi and Tim White, ask about health care?

Here are the top 11 questions most likely not to be asked:

What does Rhode Island need to do to address the unmet dental needs of its older residents?

Do you believe that the Medicaid rates for dentists providing care for adults should be increased?

How would you describe the importance of community health centers to meeting health needs of Rhode Island, and where would they fit into your budget priorities?

Do you believe that more investment should be made in community-based health equity zones to achieve better population health outcomes in Rhode Island?

Yes or no, do you believe that there are too many hospital beds in Rhode Island today?

What can Rhode Island do to improve the affordability of drug prices?

Do you believe that more needs to be done to promote vaccinations and flu shots?

Do you believe that a study needs to be commissioned to look at the problem of lead contamination in drinking water in Rhode Island?

How are access to affordable housing and access to health care related?

How much do you pay a month for your health insurance plan?

Do you believe that pre-existing conditions should be required to be covered as part of health insurance plans?

Richard Asinof is an award-winning journalist who frequently writes about health, innovation, science, technology and community in Rhode Island. He is the founder and editor of ConvergenceRI, an online newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island. He can be reached at RichardAsinof@gmail.com.